Nigerian Journal of Paediatrics

Breastfeeding practices and determinants in infants from birth to six months in a district of

Niger J Paediatr 2016; 43 (3):180 – 185

ORIGINAL

Micondo KH

Oyenusi EE

Breastfeeding practices and

Folquet AM

determinants in infants from birth

Dainguy M

to six months in a district of Abidjan

Kouadio E

Kouakou C

- Cote d’ivoire

DOI:http://dx.doi.org/10.4314/njp.v43i3.5

Accepted: 26th April 2016

Abstract : Introduction: Exclusive

(91.5%) and the median (range)

breastfeeding (EBF) has the bene-

age was 74 (2-180) days with a

Oyenusi EE

(

)

fits of reduced rates of infectious

M:F ratio of 1.18.

Department of Paediatrics,

morbidity and mortality. How-

More than half of mothers received

College of Medicine, University of

Lagos & Lagos University Teaching

ever, the EBF rate remains low

advice on breastfeeding (57.2%)

Hospital Idi-Araba Lagos

worldwide including in Côte

mainly by a health care provider

Email: ebikike@yahoo.com

d'Ivoire despite efforts by health

(83%). The overall breastfeeding,

authorities.

EBF, predominant breastfeeding

Micondo KH

Objective: The study was carried

and mixed feeding rates were

Department of Paediatrics,

out to describe the knowledge and

79.9%, 43.3%, 46.84% and 18.9%

Military Hospital, Abidjan, Cote

practices of mothers concerning

respectively. Initiation rate of

d’Ivoire/Paediatric Endocrinology

infant feeding especially with

breastfeeding within the first hour

Training Centre for West Africa

regards to breastfeeding from

was

29%.The

maternal

age

(PETCWA), Lagos University

Teaching Hospital, Idi-Araba Lagos

birth to six months and to identify

(p=0.007) and low birth weight of

factors influencing these prac-

the infant (p=0.023) were signifi-

Dainguy M, Folquet AM, Kouadio E,

tices.

cantly associated with EBF. Other

Kouakou C

Methods: This was a descriptive

factors associated with EBF in-

Department of Paediatrics,

and cross-sectional study con-

clude the mother’s occupation and

Coccody Teaching Hospital, Abidjan,

ducted over a one-month period

being married.

Cote d’Ivoire.

(1^st to 31^st August 2014)at a hos-

Conclusion: Despite the high over-

pital in Abobo-Avocatier.

all rate of breastfeeding in the

Results: A total of 318 mothers

study, EBF rates and timely initia-

and their infants were recruited.

tion of breastfeeding after birth

The median (range) age of the

need to be improved. Awareness

mothers was 27 (14-40)years.

campaigns need to be strengthened

Over half (64.5%) had some form

and interventions instituted to

of formal education, 78.9% lived

scale up optimal breastfeeding

with a partner while 24.5% were

practices.

unemployed. The HIV status was

unknown in 29.6% of cases. The

Keywords : Infants, breastfeeding,

majority of infants (94%), were

determinants, birth, Cote d’Ivoire,

born at term through vaginal route

six months.

Introduction

within the first hour after birth, to practice exclusive

breastfeeding during the first six months and continue

In 1990, United Nations Children’s Fund (UNICEF),

breastfeeding for two years and beyond, while starting

World Health Organisation (WHO) and all institutions

safe and age-appropriate complementary feeding from

the age of six months.

working for improved child nutrition adopted the decla-

ration which stated that "inadequate nutritional prac-

However, the success and continuation of breast-feeding

tices, such as the absence or inadequacy of breastfeeding

depend on several factors such as awareness, socio-

cultural factors, maternal conditions amongst others.

remain the greatest threat against child health and sur-

vival in the world. Improving breastfeeding can save

Worldwide, only 38% of infants aged zero to six months

are exclusively breastfed. In Africa, the rate of exclu-

more than 3500 lives of children every day, more than

any other intervention in preventive medicine ". Thus,

sive breastfeeding varies from one region to another. In

for optimal nutrition, WHO and UNICEF jointly devel-

some West African countries exclusive breastfeeding

rates are estimated at 20% (Cameroon in 2011) , 23%

oped the “Global Strategy for the Infant and Young

(Niger in 2012) , 39% (Senegal in 2010) and 17%

Child”. Its recommendation was to initiate breastfeeding

181

(Nigeria in 2013).

classified as: exclusive breastfeeding; breast milk &

In Côte d'Ivoire, the practice of breastfeeding is wide-

water; breast milk, water & other liquids, breast milk &

spread. However, the exclusive breast feeding as de-

porridge. The anthropometric indicators, weight for

fined by the WHO and recommended for the first six

length (W/L) and weight for age (W/ A) were used to

months of life is not a common practice. Since 1991,

assess the nutritional status of the infants according to

integrated strategies in Cote d’Ivoire have improved the

the classification by WHO Global Database on Child

Growth and Malnutrition”. Any child with a z score> -2

rate of initiation and continuation of breastfeeding. Fur-

thermore,

the exclusive breastfeeding rate increased

was considered well nourished.

from 4% in 2006 to 12% in 2012. However, more ef-

forts are needed to improve exclusive breastfeeding

Data management and analysis

rates in order to approach and hopefully surpass the esti-

mated percentage of 39% in many developing coun-

The data obtained were entered into Epi Data and ana-

tries. Therefore this study was undertaken to describe

lyzed using the Statistical Package for the Social Sci-

the knowledge and practices of mothers concerning in-

ences (SPSS) 17.0 software. Bivariate and multivariate

fant feeding especially with regards to breastfeeding

logistic regression analysis were performed to determine

from zero to six months and to identify factors influenc-

the factors affecting the choice of infant feeding. Prob-

ing these practices. It is hoped that knowledge of these

ability (p value) of <0.05 was taken as statistically sig-

factors can help in addressing the hindrances with subse-

nificant.

quent promotion of exclusive breastfeeding in Cote

d’Ivoire.

Results

Subjects and methods

During the study period, 318 mothers were interviewed.

Table 1 shows the characteristics of mothers. The me-

The study was conducted at the immunization and pae-

dian (range) age of the mothers was 27 (14-40) years,

diatric outpatient clinic of Henriette Konan Bedie, hos-

with the majority being aged between 19 and 34 years

pital. This is a primary-level health facility, located in

(84.2%). Over a third (35.5%) of mothers had no form

Avocatier-Abobo, the most populous town in Abidjan

of formal education. A great percentage (78.9%) lived

with a population estimated at 112,969 inhabitants. It is

with a partner and a quarter of them were unemployed

the most attended out of the nine health facilities that

(24.5%). The majority of mothers (81.4%) had at least

make up the health district of Abobo- East.

four antenatal clinic visits as well as anti-tetanus vacci-

It was a descriptive and analytical cross sectional study

nations (87.1%). One third (38.7%) of the mothers were

undertaken from 1st to 31 of August 2014. Approval

primiparous and about 29.6% were not aware of their

was obtained from the Human Research and Ethics

HIV status.

Committee of the hospital and authorization also from

the management before commencement of the study.

Table 1: Socio-Demographic Characteristics of Mothers

Oral informed consent was also obtained from all par-

Maternal characteris-

Number of

Percentages

ticipating mothers. All the mothers and their infants

tics

Mothers

(%)

aged from 0 to 6 months in whom informed consent was

(N=318)

(n)

obtained were included in the study. Infants whose

Age (years)

mothers were absent or had no mother-child health re-

<19

3.77

cords were excluded.

[19-35]

268

84.2

>35

11.95

Data Collection

Education level

No formal education

113

35.5

The mother-infant pairs were enrolled at the time they

Primary

29.6

Secondary

23.9

visited the facility during the entire period of the study.

Tertiary

11.0

After obtaining informed consent, mothers were inter-

Profession

viewed individually by the investigating physician and

unemployed

24.5

information obtained was entered into a research pro-

Petty traders

196

61.6

forma. Data collected included socio-demographic char-

Civil servants

3.5

acteristics of the mothers such as age, marital status,

Student

10.5

education and occupation. Other information obtained

Marital status

includes details of the antenatal period and consultations

Single

21.1

by the mother. Characteristics of the infants such as age,

Cohabitation

29.2

sex, birth-weight, feeding mode, nutritional status,

Legally married

158

49.7

health status, and vaccination status were also obtained.

HIV status

Known

224

70.4

The mothers were also interviewed to obtain informa-

Unknown

29.6

tion concerning their knowledge, attitudes and practices

Parity

about infant feeding whether breastfeeding, artificial

Primiparous

123

38.7

milk only or mixed feeding (breast milk and artificial

Pauciparous

185

58.2

milk). Furthermore, breastfeeding practices were then

Multiparous

3.1

182

The characteristics of the infants are shown in Table 2.

menced artificial milk because they felt that breast milk

The median (range) age was 74 (2-180) days with a

was insufficient. One hundred and thirteen mothers

slight male preponderance (M:F- 1.18). A large propor-

(35.5%) said they knew how to prepare infant formula,

tion of the infants (94%) were born at term with vaginal

however on further in-depth interview where they had to

delivery being the predominant route of delivery

describe the procedure, slightly more than half of them

(91.5%). As much as 90.3% of infants were delivered

(62.8%) knew how to prepare artificial milk effectively.

within a health facility. With regards to the birth-

The advantages ascribed to artificial milk and the per-

weights of the infants, almost three quarters (72.3%)

centages of mothers respectively include adequate

weighed 2500g and 3500g. Most infants (92.5%) had

growth of infants (43.4%) and liberty to go about their

completed their immunization to date as at the time of

business(27.3%).However, 87.7% of mothers recog-

the study, and had a good nutritional status (98.4%).

nized that artificial milk can cause digestive disorders

There were only five (1.6%) infants out of the study

such as constipation, abdominal colic and vomiting in

population of 318 who were sick at the time of study.

their infants.

Table 2: Characteristics of infants

Practices of mothers regarding infant feeding

Characteristics of infants

Numbers of

Percentage

(N=318)

infants (n)

(%)

Table 3 shows the different practices of mothers con-

Place of birth

cerning breastfeeding. Some form of breastfeeding was

At home

9.7

practiced by 79.9% of mothers. Other forms of infant

Health facility

287

90.3

feeding practiced were only artificial milk in 4 cases

Mode of delivery

(1.3%) and mixed feeding in 18.9% of them. The pro-

Vaginally

291

91.5

portion of mothers who commenced breastfeeding in the

Caesarean

8.5

first hour of the birth of the baby is slightly more than a

Duration of gestation

Preterm

6.0

quarter (29%) and less than half of them (43.3%) actu-

Term

299

94.0

ally practiced EBF. In most instances, (78.3%) the

Sex

mothers breastfed on demand and many mothers

Male

172

54.1

(80.2%)had never practiced manual expression of breast

Female

146

45.9

milk. For mothers who practiced mixed feeding, artifi-

Birth weight (g)

cial milk was introduced in the first month in 70% of

<2500

15,7

cases. Mothers gave water in addition to milk in 60% of

[2500-3500]

230

72,3

cases. The main reason given by 50.3% of mothers was

>3500

12,0

that the child was thirsty .Other liquids and cereals apart

Age (months)

from water given by mothers include porridge (11.6%)

[0-1[

11.9

and honey or juice (4%). Mothers who gave honey be-

[1-3[

137

43.1

lieved “it makes the child intelligent” and fruit juice

[3-6[

143

45.0

“helps digestion for the baby”. In view of these prac-

Nutritional Status

W/A> - 2 SD Z score*

264

83.0

tices, the calculated predominant breastfeeding rate was

W/H>- 2 SD Z score**

313

98.4

46.84%.

Acute illness

Healthy

313

98.4

Table 3: Breastfeeding practices of mothers

Sick infants

1.6

Practices

No of

Percentage

mothers

* Absence of underweight ** Absence of acute malnutrition

Exclusive breastfeeding

110

43.3

Breast milk and water

107

42.12

Knowledge of mothers concerning infant feeding

Breast milk, water and other liquids

5.9

Breast milk and porridge

8.66

More than half of mothers reported having received ad-

Total

254

100.0

vice on breastfeeding (57.2%) and more often, the infor-

mation had been provided by a health care provider

Factors influencing infant feeding mode

(83%). The majority of mothers (93.1%) knew the defi-

nition of exclusive breastfeeding, however one quarter

The relationship between the age of the mothers and

of them (25.8%) did not know the duration. The optimal

mode of infant feeding is shown in Table 4. Mothers

duration of the entire breastfeeding period of two years

aged above 25years were more likely to practice EBF

recommended by WHO was unknown in 92.5% of the

than those aged less than 25years (39.7% versus 24.8%)

mothers. The benefits of breast milk known by different

and this was statistically significant (p=0.008).Table 5

percentages of mothers respectively were: the low cost

shows the relationship between the mode of infant feed-

(66%), the ease of use (34.9%) and improved maternal-

ing and the marital status of the mothers. Married moth-

infant bonding (25.5%). The difficulties in breastfeeding

ers practiced more EBF than other modes of infant feed-

adduced were breast diseases(81.1%), HIV infection

ing practices when compared to unmarried mothers

(83%), untreated tuberculosis (71.7%) and mother’s

(39.9% versus 29.4%) and this was statistically signifi-

occupation (28.3%).

cant by bivariate analysis (p=0.049).A greater propor-

tion of unemployed mothers (full-time housewives)

A great majority of mothers (76.4%) said they com-

183

practiced EBF compared to working mothers whether

them reported having received advice on breastfeeding

self-employed, in private or government employment

especially from a health care provider. Concerning the

(42.3% versus 32.1%) though this was not statistically

knowledge of the mothers, even though many of them

significant (p=0.099). When multivariate logistic regres-

knew some benefits of breast milk, there were still a lot

sion analysis was done, only the parameters “older age

of knowledge gaps. Indeed, only 7.5% of mothers knew

of the mother (25- 40years)” and “having an infant with a

about the optimal duration of breastfeeding as recom-

birthweight greater than 2500g” (with p values of 0.007

mended by WHO and one quarter of them (25.8%) did

and 0.023 respectively) as shown in table 6 were signifi-

not know the duration of exclusive breastfeeding

(EBF).A study by Oche conducted in Northern Nigeria

cantly associated with EBF.

also demonstrated that only 31% of mothers had ade-

Table 4: Relationship between the age of the mothers and

quate knowledge of EBF. The identified knowledge

mode of infant feeding

gaps about EBF may be due to inadequacy of effective

education, counseling and dissemination of appropriate

EBF

Other modes of infant

feeding

information on EBF to pregnant women in the antenatal

Age of mother

Frequency

Percent-

Frequency

Percentage

clinics and also to the general populace.

age (%)

(%)

< to 25 years

24.8

75.2

A high rate of breastfeeding was found in the current

≥ 25 years

39.7

126

60.3

study, just as has been documented by other authors

P=0.008 (statistically significant)

12-14

from various countries.

It was also impressive that

٭ Breastfeeding+ artificial milk or artificial milk only

majority of infants were delivered in a health facility.

However the rate of recommended timely initiation of

Table 5: Relationship between the marital status of mothers

breastfeeding was quite low. This rate was lower than an

and mode of infant feeding

earlier rate of 30.8% reported by demographic and

health survey (DHS) in Cote d’Ivoire in 2012. However

EBF

Other modes of feed-

Marital status

ing

the rate is higher than the rates of 8% and 19.6% docu-

of mothers

fre-

Percentage

fre-

Percentage

mented in a Nigerian and Cameroonian study respec-

quency

(%)

quency

(%)

tively. In contrast, a Nepal study

reported a higher

Married

39.9

60.1

timely breastfeeding initiation rate of 72.7%. The reason

Not married

29.4

113

70.6

for the low rate of timely initiation of breastfeeding ob-

P=0.049 ( statistically significant)

served in this study, despite majority of the deliveries

Table 6: Factors affecting exclusive breastfeeding

occurring in a health facility is not immediately clear. It

may be that health workers have not provided the neces-

Exclusive Breast-

Odds

Standard

Confidence

feeding

ratio

Deviation

value

Interval 95%

sary counselling, encouragement and enabling environ-

ment to the mothers for timely initiation of breastfeed-

Age of mother

2.19

0.64

2.68

0.007*

(1.23-3.89)

25-40 years

ing. Occasionally also, deliveries by caesarean sections

Maternal education

1.13

0.30

0.44

0.662

(0.66-1.91)

in some settings cause some initial separation between

(>Secondary)

mother and the infant thus delaying initiation of breast-

Maternal Occupation

1.55

0.40

1.69

0.092

(0.93-2.58)

Housewife/Student

feeding. Another possible reason commonly encoun-

Parity

0.74

0.21

-1.04

0.299

(0.43-1.30)

tered in African settings is the common use of pre-

More than one child

lacteal feeds such as water, glucose water and formula

Marital status

1.59

0.41

1.82

0.069

(0.96-2.63)

Married

feeds because of some socio-cultural myths and beliefs

Mode of delivery

0.96

0.43

-0.09

0.925

(0.40-2.29)

about

the

safety

and

“impureness”

colos-

trum. Timely initiation of breastfeeding should be en-

Caesarean Section

Knowledge of HIV

1.11

0.30

0.40

0.69

(0.66-1.89)

couraged after all deliveries because studies have shown

Status

Unknown

that delayed onset of breastfeeding increases the risk of

Advice on successful

0.85

0.38

-0.36

0.715

(0.36-2.02)

neonatal mortality in Sub-Saharan Africa and neonatal

breastfeeding

None

mortality could be significantly reduced by 16% if the

Source of informa-

0.86

0.37

-0.35

0.715

(0.37-2.00)

mothers started breastfeeding at day one and 22% when

tion on breastfeeding

breastfeeding was commenced within the first hour.

Other than a health

worker

At the time of the survey, almost half of the mothers in

Underweight

0.82

0.28

-0.58

0.563

(0.18-0.88)

the index study were still practicing exclusive breast-

Nil

Birth weight

0.40

0.16

-2.28

0.023*

(0.18-0.88)

feeding. This was lower than a rate of 78.7% in a North-

ern Nigerian study and higher than a rate of 23.5% in a

Greater than 2500g

Northern Cameroonian study. The differences may be

Constant

0.36

0.17

-2.21

0.027*

(0.14-0.89)

Logistic regression model

related to geopolitical factors, socio-cultural factors and

* Statistically significant

age of the infants.

In the present study, mothers aged over 25 years were

Discussion

found to be more likely to breastfeed exclusively than

younger mothers. A somewhat similar report of younger

In the current study, a sizeable number of mothers had

maternal age, being a significant independent predictor

some form of formal education. In addition over half of

of early cessation of breastfeeding was reported by a

184

(PMTCT) services.

24,25

Western Australian study. A possible reason is that

This makes antenatal care a vital

older mothers may have more knowledge and experi-

component of efforts to prevent MTCT of HIV. Further-

ence of the advantages and techniques of breastfeeding

more, as much as 18.9% of respondents in the index

than the younger ones. Furthermore, most younger

study admitted to practising mixed feeding. Exclusive

mothers may likely also be primiparous and may lack

breastfeeding for the first six months is associated with a

confidence in insisting on the practice of EBF and may

3-4 fold lower risk of HIV transmission in perinatally

exposed infants as compared to mixed feeding.

bow to pressure by grandmothers, husbands and other

It is

relatives as can occur in many cultural settings including

believed that mixed feeding in the first six months car-

Africa. However, a Chinese study documented a con-

ries a greater risk of transmission because the other liq-

trary finding where EBF was positively related to a

uids and foods given to the baby alongside the breast-

younger age of the mother. Also, low infant birth weight

milk can damage the already delicate and permeable gut

significantly reduced an infant’s chances of exclusive

wall of the small infant and allow the virus to be trans-

mitted more easily. Mixed feeding also poses the same

breastfeeding. Establishment and maintenance of breast-

feeding in preterm low birth weight (PT LBW) neonates

risks of contamination and diarrhoea as artificial feed-

ing, diminishing the chances of survival. Therefore,

after discharge from hospital is challenging and may be

affected by multiple factors as has been documented by

knowledge of the infected mothers about their HIV

a Bangladesh study.

Factors significantly associated

status will empower them to make optimal choices of

with EBF in PT LBW included shorter duration of hos-

feeding for their infants for improved outcomes.

pital stay, method of feeding at discharge, mode of de-

Limitations: There may have been some individual and

livery, below average socio-economic status, maternal

other socio-cultural factors affecting breastfeeding prac-

education, number of antenatal visits and larger birth

tices that were not explored in the study.

weight. Sometimes, parents have not adhered to ideal

breastfeeding practices because of impatience and over-

zealousness to achieve catch-up in the weight of their

Conclusion

preterm babies.

Majority of the mothers had received advice on breast-

Married mothers were also found to be breastfeeding

feeding and delivered within a health facility. Even

more frequently than single mothers as has also been

though the rate of breastfeeding was high, the percent-

documented by a Ghanian and Chinese study respec-

age of mothers who initiated timely breast feeding was

tively. It is obvious that the support of the husband im-

not optimal. The EBF rate is still not as high as desired.

proves the rate of breastfeeding. The mother’s occupa-

Older mothers and mothers of infants with normal birth

tion though, not statistically significant also influenced

weight were factors significantly associated with the

the choice of infant feeding mode in the current study.

practice of exclusive breastfeeding. There is a need to

Students and house wives were more likely to breastfeed

institute interventions aimed at early initiation of breast-

exclusively and longer than working mothers. A Camer-

feeding. Strengthening infant feeding advice/counseling

oonian study also reported that being a housewife was

both at the community and institutional levels in addi-

significantly associated with EBF. It may be that full-

tion to promotion of good breast-feeding practices

time housewives are always available to breastfeed or

among expectant mothers and also the community, espe-

may limited by the financial resources for the regular

cially the families, taking into account the local tradi-

purchase of artificial milk.

tions and customs is advocated. Younger mothers and

mothers of low birth weight babies should be also tar-

Another important finding worthy of mention in the cur-

geted for effective counseling and support on EBF.

rent study is that, nearly a third of mothers did not know

their HIV status even though most of them had at least

four antenatal visits. This is in agreement with a study

Acknowledgements

across Sub-Saharan Africa which documented that preg-

nant women from West African countries had a lower

The authors hereby acknowledge the mothers and in-

rate of HIV testing as part of antenatal care compared to

fants who participated in this study. We also want to

their counterparts from Eastern and Southern Africa.

appreciate Gro BAM, Djivohessoun A, Djoman I, An-

This may be due to ignorance on the side of the women

gan GA of the Department of Paediatrics, Coccody

and lack of training or excessive workload on the part of

Teaching Hospital, Abidjan Cote d’Ivoire for their sup-

the healthcare providers. In addition, due to persistence

port during the research work and other research assis-

of stigmatization against people living with HIV in

tants who contributed to the work. We also acknowledge

many parts of the West African subregion,

women

the statistician, Mr K Martial for his assistance in data

may be reluctant to find out their HIV status in case it is

analysis.

positive. Mother-to-child transmission (MTCT), is the

most common cause of paediatric HIV infection, often

Author's contributions

occurring during pregnancy, birth or breastfeeding.

MKH: Carried out the interviews and collection of data.

Current guidelines recommend inclusion of HIV testing

DM, FAM, KE, KC: Supervised the work. MKH and

in routine screening tests for all pregnant women be-

OEE wrote the manuscript. All the authors read and ap-

cause knowledge of HIV status allows pregnant women

proved the final manuscript.

access to prevention of mother-to-child transmission

Conflict of interest: None

Funding: None

185

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